Medium-energy shock wave therapy in the treatment of rotator cuff calcifying tendinitis

To evaluate the results of the treatment with medium-energy extracorporeal shock wave therapy (ESWT) in rotator cuff calcifying tendinitis. Fifty-four non-consecutive patients, who were referred to our institute for rotator cuff calcifying tendinitis, were managed with a standardized protocol in four sessions of medium-energy (0.11mJ/mm2) ESWT administered with an electromagnetic lithotriptor. Pain was evaluated at the end of each session, functional state of shoulder was assessed at 1 and 6months after the end of procedure. All patients underwent radiographs and sonography imaging. No systemic or local complications. Thirty-eight patients (70%) reported satisfactory functional results. Radiographs and sonographs showed a disappearance of calcium deposit in 29 patients (54%) and in 19 patients (35%) it appeared to be reduced more than a half. A correlation was found between residual calcium deposit and the clinical outcome, but some patients showed a reduced pain without modification of calcium deposit. These results were unmodified at 6months follow-up. Our protocol of medium-energy ESWT provides good results overall about pain modulatio

Multilobulated popliteal cyst after a failed total knee arthroplasty

Popliteal cyst is a rare finding after total knee arthroplasty (TKA), but when present, it might indicate a malfunction of the TKA related to generation of wear-particles, or loosening. We present a case of a multilobulated popliteal cyst developing in a patient 8years after primary TKA. The cyst was associated with a mechanical prosthetic loosening. The primary complaint of the patient was pain in the posterior region of the knee. A two-stage procedure consisting of cyst excision at first, followed after 5months by a revision TKA was performed. Intraoperatively, a darkish, multilobulated cyst with a well-defined thick wall filled with fluid containing polyethylene debris, communicating with the knee joint was found. After 3years of follow-up, the patient was satisfied and walked without the support of a cane. The patient presented a satisfactory knee range of motion. Clinical, radiological and ultrasound investigations ruled out popliteal cyst recurrence. A dissecting popliteal cyst associated with a failed TKA should be excised because it contains polyethylene debris that constitutes an induced factor for prosthetic loosening. A two-stage procedure with quite a long time in-between, as presented in this paper, can be a useful alternative to manage such a problem, in particular in very old patients associated with other medical problem

Extracorporeal shock wave therapy in runners with a symptomatic heel spur

The aim of this paper is to assess the benefit to treat plantar fasciitis with low-dose energy extracorporeal shock wave therapy (ESWT) and the efficacy of such treatment to abate the painful symptoms allowing a rapid return to the running activity. Our study included 54 running athletes treated for plantar fasciitis associated with a heel spur who received four sessions (once weekly) of low-dose ESWT, and followed prospectively on average 45days, 6 and 24months after their last session. The clinical results were excellent in 59% of cases, good in 12%, satisfactory in 21% and distinctly unsatisfactory in 8%. No patient was observed a significant modification of the heel spur at the follow-up X-ray. The ultrasound examination at 24months showed a disappearance of the inflammation signs in 61% of cases. A strong correlation between ultrasound improvement and clinical results were found. Low-energy ESWT seems to be a good mean to treat plantar fasciitis in runners with a 71% of good or excellent results and a persistent improvement lasting 24months. A randomized multicentric study seems to be necessary to define the type of energy that should be used in the future to treat plantar fasciitis, in particular in the athletic patients, to allow a faster return to sports activitie

The management of neuropathic ulcers of the foot in diabetes by shock wave therapy

<p>Abstract</p> <p>Background</p> <p>Diabetes is becoming one of the most common chronic diseases, and ulcers are its most serious complication. Beginning with neuropathy, the subsequent foot wounds frequently lead to lower extremity amputation, even in the absence of critical limb ischemia. In recent years, some researchers have studied external shock wave therapy (ESWT) as a new approach to soft tissue wound healing. The rationale of this study was to evaluate if ESWT is effective in the management of neuropathic diabetic foot ulcers.</p> <p>Methods</p> <p>We designed a randomized, prospective, controlled study in which we recruited 30 patients affected by neuropathic diabetic foot ulcers and then divided them into two groups based on different management strategies. One group was treated with standard care and shock wave therapy. The other group was treated with only standard care. The healing of the ulcers was evaluated over 20 weeks by the rate of re-epithelization.</p> <p>Results</p> <p>After 20 weeks of treatment, 53.33% of the ESWT-treated patients had complete wound closure compared with 33.33% of the control patients, and the healing times were 60.8 and 82.2 days, respectively (p < 0.001). Significant differences in the index of the re-epithelization were observed between the two groups, with values of 2.97 mm²/die in the ESWT-group and 1.30 mm²/die in the control group (p < 0.001).</p> <p>Conclusion</p> <p>Therefore, ESWT may be a useful adjunct in the management of diabetic foot ulceration.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN21800909</p

Phenotyping of chondrocytes from human osteoarthritic cartilage: chondrocyte expression of beta integrins and correlation with anatomic injury

Chondrocyte-ECM (extracellular matrix) interactions are believed to play a pivotal role in the development and metabolic homeostasis of articular cartilage. Cell surface adhesion molecules have been reported to modulate chondrocyte binding to ECM (collagen, fibronectin, laminin) and they also act as transducers of critical signals in many biological processes such as growth, differentiation, migration and matrix synthesis. Recently, it has been shown that normal human articular chondrocytes strongly express beta1 integrins, which are constituted by a common chain (beta1) and a variable alphachain, but the behaviour of these molecules in human osteoarthritic cartilage has not been extensively investigated. We studied the expression of beta integrins (beta1-5, alpha1-6, av chains), LFA-1, ICAM-1 and CD44, on freshly isolated chondrocytes obtained from 10 osteoarthritic patients undergoing surgical knee replacement. Chondrocytes were isolated by enzymatic digestion from three zones of each articular cartilage with a differing degree of macroscopic and microscopic damage. Integrin expression and cell cycle analysis were carried out by flowcytometry. Chondrocytes from costal cartilages of 5 human foetuses were also studied. Chondrocytes from osteoarthritic cartilage expressed high levels of beta1 integrin and, at different percentages, all the alphachains. The alphachain most frequently expressed was alpha1, foilowed by alpha3, alpha5, alpha2, alphav. Integrin expression decreased from the least to the most damaged zone of articular cartilage and cell cycle analysis showed that proliferating chondrocytes (S phase) were prevalent on the latter zone. beta2, beta3, beta2, beta5, CD44, LFA-1/ICAM-1 complex were very low expressed. Fetal chondrocytes strongly expressed beta1 and beta5 chains. These data provide evidence to show that integrin expression on human chondrocytes changes in osteoarthritis and suggest that perturbations of chondrocyte-ECM signalling occur in the development of the disease. The different pattern of expression of beta1 and beta5 chains on adult and fetal chondrocytes leads to speculate that integrins play a key role in control of cartilage morphogenesis and differentiation

The incidence of hip, forearm, humeral, ankle, and vertebral fragility fractures in Italy: results from a 3-year multicenter study

INTRODUCTION: We aimed to assess the incidence and hospitalization rate of hip and "minor" fragility fractures in the Italian population. METHODS: We carried out a 3-year survey at 10 major Italian emergency departments to evaluate the hospitalization rate of hip, forearm, humeral, ankle, and vertebral fragility fractures in people 45 years or older between 2004 and 2006, both men and women. These data were compared with those recorded in the national hospitalizations database (SDO) to assess the overall incidence of fragility fractures occurring at hip and other sites, including also those events not resulting in hospital admissions. RESULTS: We observed 29,017 fractures across 3 years, with hospitalization rates of 93.0% for hip fractures, 36.3% for humeral fractures, 31.3% for ankle fractures, 22.6% for forearm/wrist fractures, and 27.6% for clinical vertebral fractures. According to the analyses performed with the Italian hospitalization database in year 2006, we estimated an annual incidence of 87,000 hip, 48,000 humeral, 36,000 ankle, 85,000 wrist, and 155,000 vertebral fragility fractures in people aged 45 years or older (thus resulting in almost 410,000 new fractures per year). Clinical vertebral fractures were recorded in 47,000 events per year. CONCLUSIONS: The burden of fragility fractures in the Italian population is very high and calls for effective preventive strategies

Extracorporeal shock waves down-regulate the expression of interleukin-10 and tumor necrosis factor-alpha in osteoarthritic chondrocytes

<p>Abstract</p> <p>Background</p> <p>The purpose of this study was to investigate the effects of extra corporeal shock waves (ESW) therapy on the metabolism of healthy and osteoarthritic human chondrocytes, and particularly on the expression of IL-10, TNF-alpha and beta1 integrin.</p> <p>Methods</p> <p>Human adult articular cartilage was obtained from 9 patients (6 male and 3 females), with primary knee osteoarthritis (OA), undergoing total joint replacement and from 3 young healthy donors (HD) (2 males, 1 female) with joint traumatic fracture. After isolation, chondrocytes underwent ESW treatment (electromagnetic generator system, MINILITH SL1, STORZ MEDICAL) at different parameters of impulses, energy levels and energy flux density. After that, chondrocytes were cultured in 24-well plate in DMEM supplemented with 10% FCS for 48 hours and then beta₁integrin surface expression and intracellular IL-10 and TNF-alpha levels were evaluated by flow-cytometry.</p> <p>Results</p> <p>At baseline, osteoarthritic chondrocytes expressed significantly lower levels of beta1 integrin and higher levels and IL-10 and TNF-alpha levels. Following ESW application, while beta1 integrin expression remain unchanged, a significant decrease of IL-10 and TNF-alpha intracellular levels was observed both in osteoarthritic and healthy chondrocytes. IL-10 levels decreased at any impulses and energy levels, while a significant reduction of TNF-alpha was mainly found at middle energies.</p> <p>Conclusion</p> <p>Our study confirmed that osteoarthritic chondrocytes express low beta₁integrin and high TNF-alpha and IL-10 levels. Nonetheless, ESW treatment application down-regulate the intracellular levels of TNF-alpha and IL-10 by chondrocytes, suggesting that ESW might restore TNF-alpha and IL-10 production by osteoarthritic chondrocytes at normal levels. However, further in vivo and in vitro studies are necessary to establish if ESW can represent a viable option in the treatment of OA.</p

The role of the immune system in the physiopathology of osteoporosis

The close anatomical relationship between the immune system, estrogen deficiency and bone loss has been recognized for centuries but the existence of a functional relationship has emerged only recently. The role of the immune system in the development of senile osteoporosis, which arises primarily through the effects of estrogen deficiency and secondary hyperparathyroidism, is slowly being unraveled. This review focuses the evidence that links immune cells, inflammation, cytokine production and osteoclast formation and their activity. The under standing of the interplay of inflammation and osteoclast can lead to the development of new drugs for prevention and treatment of bone los

Surgical approach to bone healing in osteoporosis

Osteoporotic fractures represent one of the most common cause of disability and one of the major voice in the health economic budget in many countries of the world. Fragility fractures are especially meta-epiphyseal fractures, in skeletal sites with particular biomechanic characteristic (hip, vertebrae), complex and with more fragments, with slow healing process (mineralization and remodeling) and co-morbidity. The healing of a fracture in osteoporotic bone passes through the normal stages and concludes with union of the fracture although the healing process is prolonged. Fractures in the elderly osteoporotic patients represent a challenge to the orthopaedic surgeons. Osteoporosis does not only increase the risk of fracture but also represents a problem in osteofixation of fractures in fracture treatment. The major technical problem that surgeons face, is the difficulty to obtain a stable fixation of an implant due to osteoporotic bone. The load transmitted at the bone-implant interface can often exceed the reduced strain tolerance of osteoporotic bone. In the treatment of osteoporotic fractures it is important to consider different aspects: general conditions of elderly patient and comorbidity, the reduced muscular and bone mass and the increased bone fragility, structural modifications as medullary expansion. The aim of surgical treatment is to obtain a stable fixation that reduces pain and permits an early mobilizatio